Abstract Background and Purpose: Typical lengths of stay after open cystectomy are 5 to 7 days, without dramatic differences reported for laparoscopic or robot-assisted cystectomy. We developed a clinical pathway for early discharge after robot-assisted cystectomy, attempting to take advantage of potentially decreased morbidity with this minimally invasive procedure and analyzed our initial outcomes. Patients and Methods: The initial 30 consecutive patients undergoing robot-assisted cystectomy who were treated on a clinical pathway developed at our institution were reviewed. This included an extraction incision of </=3 inches also used for urinary diversion, no intensive care unit stay, no nasogastric tube, and avoidance of intravenous narcotics. Ambulation is begun on postoperative day (POD) zero, with clear liquids uniformly on POD 1, then regular diet on passing flatus. Patients are discharged when tolerating diet, with a target of POD 3. Results: Mean age was 67 years (45-87 y), and mean operative time was 411 minutes. All ambulated by POD 1. Only 4 of 30 needed any intravenous narcotics. Twenty-one patients were discharged on POD 3 and 8 on POD 4 for an overall mean of 3.3 days, including 2 who were discharged on POD 2 and 1 on POD 7. One was seen in the emergency department on POD 6 for emesis, and one was readmitted on POD 7 for candidal infection. No others returned to the clinic or hospital within a week after discharge (POD 10). Conclusion: Our clinical pathway after robot-assisted cystectomy allows shorter hospital stays than typical and is, to our knowledge, the shortest reported after cystectomy by any technique. Only two unplanned visits occurred during the first 10 days. Further experience will be necessary to confirm the initial success.

“Feasibility and early outcomes of robotic-assisted laparoscopic Mitrofanoff appendicovesicostomy in patients with prune belly syndrome.”

Wille, M. A., G. Jayram, et al. (2011).

BJU International.

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? There is a single case reported in the literature describing this approach in Prune-Belly Syndrome. To our knowledge there are two case reports and two series in which laparoscopic appendicovesicostomy using the da Vinci robotic system was performed with good results. There are also several case reports of appendicovesicostomy creation using a pure laparoscopic approach. Additionally several case reports have described combined procedures involving pure laparoscopic and robotic assisted techniques, including appendicovesicostomy with concurrent augmentation, nephrectomy, orchiopexy, antegrade continence enema and cecostomy tube placement. Nguyen et al. have a similar experience in terms of number of patients (ten) who have undergone RALMA, but have not operated on patients with PBS. To our knowledge this is the largest series of patients undergoing RALMA in patients with Prune-Belly Syndrome. OBJECTIVES: * To evaluate the feasibility and report our initial experience with Robotic- Assisted Laparoscopic Mitrofanoff Appendicovesicostomy (RALMA) in patients with prune belly syndrome. * The Mitrofanoff appendicovesicostomy procedure uses the appendix to create an easily accessible continent, catheterizable channel into the urinary bladder. Historically, the procedure is performed by an open surgical approach in prune belly patients. We describe our initial experience herein. MATERIALS AND METHODS: * Between October 2008 and February 2010 three patients with prune belly syndrome underwent RALMA. * The appendicovesicostomy anastomosis was performed on the anterior bladder wall and the stoma was brought to the umbilical site or right lower quadrant. * At least 4 cm of detrusor backing was ensured. * The appendicovesicostomy stent was left in place for 4 weeks postoperatively before initiation of catheterization. RESULTS: * Mean age at surgery was 9.7 years (range 5-14 years). * Blood loss volume was 20 mL in each case. Overall mean operative time was 352 min (range 319-402 min). There were no intraoperative complications and no open conversions. * There was one postoperative complication in the form of wound infection. * All patients are catheterizing their stomas and are continent at an average follow-up of 14.7 months (range 5-21 months). CONCLUSION: * In our initial experience, RALMA is a feasible option with encouraging early experience for creating a continent catheterizable channel into the urinary bladder in patients with prune belly syndrome.

Objective: To evaluate surgical and functional outcomes of the robotic assisted pyeloplasty cases. Materials and methods: Between August 2008 and November 2010, 12 patients underwent transperitoneal robotic (4 ports) pyeloplasty. Patients were evaluated with preoperative physical examination, intravenous urography, and diuretic renography. The presence of crossing vessels, blood loss, operative time, mean follow-up period, and perioperative complications were analyzed. Results: The mean age was 33 years (range 14-62 years). All patients underwent robotic-assisted dismembred pyeloplasty. Ureteral stent was placed in an antegrade fashion. Mean operative time was 124 min, and estimated blood loss was 80 cc. Crossing vessels were observed in 4 patients, and transposition was performed. The drain was removed after a mean of 3 days. The mean length of hospital stay was 3.6 days. One patient needed blood transfusion postoperatively. No evidence of obstruction was observed at a mean of 16-month follow-up. Conclusion: Robotic-assisted pyeloplasty with its high success rates and low morbidity is an effective, safe, and minimally invasive approach for the treatment of ureteropelvic junction obstruction.

Objective: In this study, we evaluated the predictive value of R.E.N.A.L. Nephrometry Score (RNS), a system to standardize the renal tumors according to size, location, and depth, for surgical outcomes of robotic partial nephrectomy. Materials and methods: Twenty-nine cases who underwent robotic partial nephrectomy in two institutions between 2008 and 2010 were included in the study. RNS was calculated from preoperative computed tomography and/or magnetic resonance images by considering tumor size, exophytic/endophytic properties, distance to the collecting system, anterior or posterior location, and distance to the polar lines. Total RNS less than 7 was considered as low and ≥7 as high complexity lesions. Operative time, estimated blood loss, warm ischemia time, and positive surgical margin were analyzed. Results: There were 14 low complexity tumors with a mean RNS of 5 and 15 high complexity tumors with a mean RNS of 7.9. The mean warm ischemia time was 18.6 min in low complexity tumors and 29.8 min in high complexity tumors (p=0.01). There was a strong positive correlation between RNS and warm ischemia time (r=0.57, p=0.002). The difference between low and high complexity tumors was not statistically significant in terms of operative time, estimated blood loss, length of hospital stay, and positive surgical margins. Conclusion: Preoperative RNS can predict the warm ischemia time in robotic assisted partial nephrectomy. High RNS results in longer warm ischemia time. RNS may be useful in determining surgical approach to preserve renal function in high-risk patients.

“Robotic partial nephrectomy in the setting of prior abdominal surgery.”

Dasgupta, P. (2011).

BJU International 108(3): 419.

“Comparison of the Operation Time and Complications between Conventional and Robotic-Assisted Laparoscopic Pyeloplasty.”

Garcia-Galisteo, E., E. Emmanuel-Tejero, et al. (2011).

Actas Urologicas Espanolas.

OBJECTIVE: To compare the different times into which the convention and robotic-assisted laparoscopic pyeloplasty can be divided. To compare the rate of complications between both procedures. MATERIAL AND METHODS: A retrospective study was performed of the patients diagnosed of pyeloureteral junction stenosis and treated with convention and robotic laparoscopic pyeloplasty with more than one year of follow-up. All of the interventions were recorded and visualized. The different times in which the pyeloplasty can be divided were measured. All of the peri- and post-operative complications that occurred by the patients were collected. The non-parametric tests of Kolmogorov-Smirnov and Mann-Whitney U-Test for independent samples were applied using a significance level of 0.05. RESULTS: A total of 50 patients were validated. Thirty three were treated with convention laparoscopy and 17 with robotic laparoscopy. The suture time, total intervention time and time of hospital stay were lower with a statistically significant difference in the robotic-assisted pyeloplasty. The robotic pyeloplasty had a lower percentage of complications (76.5% vs 48.5%). The most frequent complications were urinary infections, in relationship to the double J. Two restenoses occurred in the conventional laparoscopy and one in the robotic-assisted. Success rate was 93.9% for the conventional laparoscopy and 94.1% for the robotic-assisted one. CONCLUSIONS: Although the success rate is similar in both procedures, the robotic pyeloplasty is a very fast procedure and has lower rates of complications than the conventional laparoscopy.

Abstract Growing evidence supports the use of nephron-sparing techniques for the management of appropriately selected renal masses up to 7 cm. Compared with the surgical standard of open partial nephrectomy, minimally invasive approaches have demonstrated equivalent cancer control with reduced patient morbidity. Robot assistance has the potential to provide patients and physicians greater access to minimally invasive nephron-sparing surgery. We describe a robot-assisted retroperitoneal approach for the management of posterior renal masses. Our early results suggest reduced perioperative morbidity with the ability to manage more complex tumors.

“Outcomes of robotic partial nephrectomy for renal masses with nephrometry score of >/=7.”

White, M. A., G. P. Haber, et al. (2011).

Urology 77(4): 809-813.

OBJECTIVES: To evaluate the safety and feasibility of robotic partial nephrectomy for patients with complex renal masses. METHODS: We reviewed the data for 164 consecutive patients who had undergone transperitoneal robotic partial nephrectomy at a tertiary care center from February 2007 to June 2010. Of the 112 patients who had available imaging studies to review, 67 were identified and classified as having a moderately or highly complex renal mass according to the R.E.N.A.L. nephrometry score (>/=7) (tumor size-[R]adius, location and depth-[E]xophytic or endophytic; nearness to the renal sinus fat or collecting system [N]; anterior or posterior position [A], and polar vs non-polar location [L]). The preoperative, perioperative, pathologic, and functional outcomes data were analyzed. RESULTS: The median body mass index was 29.6 kg/m(2) (range 19.9-44.8). Of the 67 patients, 32 were men and 35 were women, with 32 right-sided masses and 35 left-sided masses. The median tumor size was 3.7 cm (range 1.2-11), and the median operative time was 180 minutes (range 150-180). The median estimated blood loss was 200 mL (range 100-375), and the warm ischemia time was 19.0 minutes (range 15-26). The median hospital stay was 3.0 days (range 3-4). The estimated glomerular filtration rate was calculated at a median decrease of 11.1 mL/min/1.73 m(2) (range 9-1.3). According to the Clavien-Dindo classification of surgical complications, 2 grade 1, 12 grade 2, and 1 grade 3 complication occurred. All margins were pathologically negative, except for 1, and, after a mean follow-up of 10 months, no recurrences had developed. CONCLUSIONS: Robotic partial nephrectomy is a safe and feasible option for moderately or highly complex renal masses determined by the R.E.N.A.L. nephrometry score. The warm ischemia time, blood loss, and complications were increased with highly complex masses.

“Editorial comment for Weizer et al.”

Bhayani, S. B. (2011).

Journal of Endourology 25(4): 557-558.

“Editorial comment.”

Ghazi, A. (2011).

Urology 77(4): 967-968; author reply 968.

“Surgical case volume in Canadian urology residency: A comparison of trends in open and minimally invasive surgical experience.”

ABSTRACT: BACKGROUND: RNA quality is believed to decrease with ischaemia time, and therefore open radical prostatectomy has been advantageous in allowing the retrieval of the prostate immediately after its devascularization. In contrast, robotic-assisted laparoscopic radical prostatectomies (RALP) require the completion of several operative steps before the devascularized prostate can be extirpated, casting doubt on the validity of this technique as a source for obtaining prostatic tissue. We seek to establish the integrity of our biobanking process by measuring the RNA quality of specimens derived from robotic-assisted laparoscopic radical prostatectomy. METHODS: We describe our biobanking process and report the RNA quality of prostate specimens using advanced electrophoretic techniques (RNA Integrity Numbers, RIN). Using multivariate regression analysis we consider the impact of various clinicopathological correlates on RNA integrity. RESULTS: Our biobanking process has been used to acquire 1709 prostates, and allows us to retain approximately 40% of the prostate specimen, without compromising the histopathological evaluation of patients. We collected 186 samples from 142 biobanked prostates, and demonstrated a mean RIN of 7.25 (standard deviation 1.64) in 139 non-stromal samples, 73% of which had a RIN[greater than or equal to]7. Multivariate regression analysis revealed cell type – stromal/epithelial and benign/malignant – and prostate volume to be significant predictors of RIN, with unstandardized coefficients of 0.867(p=0.001), 1.738(p<0.001) and -0.690(p=0.009) respectively. A mean warm ischaemia time of 120min (standard deviation 30min) was recorded, but multivariate regression analysis did not demonstrate a relationship with RIN within the timeframe of the RALP procedure. CONCLUSIONS: We demonstrate the robustness of our protocol – representing the concerted efforts of dedicated urology and pathology departments – in generating RNA of sufficient concentration and quality, without compromising the histopathological evaluation and diagnosis of patients. The ischaemia time associated with our prostatectomy technique using a robotic platform does not negatively impact on biobanking for RNA studies.

“Is there any evidence of superiority between retropubic, laparoscopic or robot-assisted radical prostatectomy?”

Ferronha, F., F. Barros, et al. (2011).

International Braz J Urol 37(2): 146-158.

Purpose: To compare the perioperative, short-term and long-term postoperative results of radical retropubic prostatectomy (RRP), laparoscopic radical prostatectomy (LRP) and robotic assisted laparoscopic prostatectomy (RALP) in the most recent studies evaluable. Materials and Methods: Using PubMed we have undertaken a search based on references from major and recent articles with considerable sample sizes. Results: The operative blood loss and the risk of transfusion were lower in the laparoscopic and robotic-assisted approaches. The surgical duration was shorter in the open and robotic group. Regarding the positive margins, continence and potency no substantial differences between the RRP, LRP, and RALP were found. Conclusions: Our results suggest that no one surgical approach is superior in terms of functional and early oncologic outcomes. Potential advantages of any surgical approach have to be confirmed through longer-term follow-up and adequately designed clinical studies.

“The impact of anterior urethropexy during robotic prostatectomy on urinary and sexual outcomes.”

Johnson, E. K., R. C. Hedgepeth, et al. (2011).

Journal of Endourology 25(4): 615-619.

OBJECTIVES: We determined the effect of an anterior urethropexy (AU) stitch on postoperative urinary continence, irritative urinary symptoms, and sexual function after robotic radical prostatectomy (RP). METHODS: Consecutive patients undergoing robotic RP for prostate cancer were prospectively evaluated. The Expanded Prostate Cancer Index Composite (EPIC) questionnaire was administered pre- and postoperatively to all patients. Patients were then grouped by AU status. A linear mixed model was used to compare the rate of recovery in incontinence (UIN), irritative (UIR), and sexual domain scores between the two groups. A t-test was used to compare UIN, UIR, and sexual domain scores at specific time points. RESULTS: A total of 229 patients underwent robotic RP and filled out a preoperative and at least one postoperative EPIC questionnaire. In this population, 87 did have and 142 did not have an AU performed. The mean EPIC-UIN score at 3 months was 68 in the AU group and 58 in the non-AU group (p = 0.015). Comparison of all other time points and overall urinary scores revealed no other statistically significant differences after surgery. Sexual domain scores were also improved at 3 months in the AU group (p = 0.002). CONCLUSIONS: AU during robotic RP leads to improved urinary continence and sexual functioning at 3 months of follow-up. An earlier return to continence may facilitate an earlier return to sexual activity. AU may offer a short-term quality-of-life advantage for patients undergoing robotic RP.

“Achieving realistic postoperative expectations in the prostatectomy populationis it possible?”

Krupski, T. L. (2011).

Journal of Urology 186(2): 373-374.

“Complications and Nerve Preservation in Prostatectomy According to the Time Interval from Diagnostic Biopsy.”

Martin-Lopez, J. E., A. M. Carlos-Gil, et al. (2011).

Actas Urologicas Espanolas.

OBJECTIVES: To summarize the available evidence on complications and bilateral nerve preservation in radical prostatectomy in patients according to the time interval from diagnostic biopsy (more or less than six weeks). MATERIAL AND METHODS: Relevant studies were identified by using structured and specific search strategies for each of the databases consulted, without limitations. The methodological quality of each of the studies included was evaluated and the data were extracted independently. RESULTS: For open radical prostatectomy, two of the studies concluded that a time interval of less than 4 or 6 weeks between prostate biopsy and surgery had no influence on the postsurgical complications rate or on nerve preservation during surgery. For laparoscopic robotic-assisted radical prostatectomy, the study included concluded that performing this type of intervention in an interval of less than 4 or 6 weeks after diagnostic biopsy was associated with a higher risk of postsurgical complications. However, all these studies had major methodological limitations. CONCLUSIONS: The time interval between diagnostic biopsy and open surgery has no influence on the complications rate or nerve preservations. In contrast, an interval of less than 4 weeks between diagnostic biopsy and laparoscopic surgery is associated with a higher risk of surgical complications.

“Comparative assessment of a single surgeon’s series of laparoscopic radical prostatectomy: conventional versus robot-assisted.”

Park, J. W., H. Won Lee, et al. (2011).

Journal of Endourology 25(4): 597-602.

PURPOSE: To directly compare the outcome of laparoscopic radical prostatectomy (LRP) with robot-assisted laparoscopic prostatectomy (RALP) performed by a single laparoscopic surgeon with intermediate experience-one who is between a novice and an expert. PATIENTS AND METHODS: Consecutive 106 patients with prostate cancer who were treated with radical prostatectomy (62 with LRP and 44 with RALP) were included. The preoperative characteristics, the perioperative surgical outcomes, and the functional outcomes were compared between the two groups. RESULTS: The mean operative time was longer in the RALP group (371 min vs 308 min, P = 0.00), conceivably because of more nerve-sparing procedures (84% vs 57%). The other perioperative parameters, including the surgical margin, were comparable, except for two major complications (rectourethral fistula and ureteral injury) in the LRP group. The RALP group recovered continence faster than those in the LRP, but the eventual continence rate at 12 months was similar (95% for LRP vs 94.4% for RALP, P = 1.00). The potency rate >/= 6 months postsurgery was 47.6% in the LRP group and 54.5% in the RALP group (P = 0.65). CONCLUSIONS: RALP was beneficial for the earlier recovery of continence, although LRP and RALP had comparable safety and efficacy as minimally invasive surgery for prostate cancer when performed by a laparoscopic surgeon with intermediate experience. Long-term follow-up data are needed for further evaluation of oncologic and functional outcomes for both techniques.

OBJECTIVES: To compare perioperative and functional outcomes after urethrovesical anastomosis (UVA) with barbed polyglyconate and monofilament poliglecaprone in robot-assisted radical prostatectomy (RARP). Barbed polyglyconate suture was first used for the UVA during RARP beginning in January 2010; safety and feasibility were previously demonstrated in 51 patients. METHODS: From May to September 2010, 64 patients meeting all the inclusion criteria participated in the present multisurgeon prospective, randomized, controlled trial and underwent posterior repair and UVA during RARP with either barbed polyglyconate (n = 33) or monofilament poliglecaprone (n = 31) suture. The primary outcomes were the anastomotic (UVA) and posterior reconstruction times. Secondary outcomes included cystogram leak, bladder neck reconstruction rate, and 6-week functional outcomes assessed by a self-administered validated patient questionnaire. RESULTS: Posterior reconstruction was performed within 3.3 minutes with the barbed suture versus 4.3 minutes with the monofilament poliglecaprone suture (23.3% reduction) and UVA within 10.1 versus 13.8 minutes, respectively (26.8% reduction). The absolute time difference for the 2-layer anastomosis was 4.7 minutes (a 26.0% reduction in the total anastomosis time). All other perioperative outcomes were equivalent between the 2 groups. Urinary functional outcomes, including the pad use and leakage rates, were equivalent at 6 weeks. CONCLUSIONS: Anastomosis during RARP with the V-Loc barbed suture can be performed safely and more efficiently than with standard monofilament suture. We demonstrated a 26% decrease in the anastomotic time with no increase in the adverse events, no instances of urinary retention and equivalent functional outcomes were measured with the self-administered patient questionnaire.

OBJECTIVES: To search online using the Google search engine to determine what information for robotic-assisted radical prostatectomy (RARP) is available and whether the claims made on the Internet are supported by the published peer-reviewed urologic data. METHODS: The term “robotic prostatectomy” was searched using Google on September 29, 2009. The first 50 Web sites were reviewed for RARP specific outcomes, including oncologic outcomes, potency, continence, recovery, and blood loss. All claims were compared with the accepted standards supported by the existing published urologic data. RESULTS: Of the first 50 Web sites, 9 were rejected. Of the remaining 41, 29 were from academic practices and 8 from nonacademic practices; for 4, this distinction was not applicable. Also, 19 sites had direct links, photographs, or text from the Intuitive Surgical Web site, and 22 sites did not. Of the 41 Web sites, 20 made no mention of surgeon experience with RARP and 21 did, with an average experience of 1487 +/- 1206 cases. More than 60% of the sites claimed better potency outcomes with RARP than with radical retropubic prostatectomy, although 32% of sites omitted this information. Similarly, 63% of the Web sites claimed improved continence with RARP than with radical retropubic prostatectomy, and 29% of the sites made no mention of continence. Data on oncologic efficacy was missing from 22% of the Web sites, 22% suggested the cancer outcomes were equivalent between RARP and radical retropubic prostatectomy, and 56% suggested the cancer outcomes were better with RARP. Concerning postoperative recovery and blood loss, 85% of the sites stated that both were improved with RARP, and only 15% omitted these data. CONCLUSIONS: Overall, an online search using the Google search engine for robotic prostatectomy yielded many Web sites with unsubstantiated information of variable accuracy.

“Clinicians’ use of guidelines as illustrated by curative treatment of prostate cancer at a comprehensive cancer center.”

Stensvold, A., A. A. Dahl, et al. (2011).

Acta Oncologica 50(3): 408-414.

BACKGROUND: We studied compliance to guidelines of curative treatments in prostate cancer (PCa), which were of special interest due to recent introduction of new treatment technologies and the fact that there existed a real choice between surgery and radiotherapy. MATERIAL AND METHODS: We did retrospective analyses of guidelines adherence for all PCa patients receiving curative treatment at the Norwegian Radium Hospital from 2004 to 2007 after the introduction of robot-assisted prostatectomy and after-loading brachytherapy. The patients were classified into three groups in relation to guidelines: the accordance, accordance after discussion, and the deviance groups. In time Period I (2004-2005) the 2003 EAU guidelines were used and in Period II (2006-2007) in-house guidelines with minor modifications of EAU were applied. RESULTS: During the observation period 859 patients had curative treatment for PCa, and 83% of the patients were treated according to guidelines. In the deviance group (N=146), 119 men (82%) got prostatectomy instead of radiotherapy. The reasons for deviation in the second period were age >65 years (N=70) and surgery in cases with T3 tumors (N=10), Gleason score >8 (N=13) and combinations (N=26). Deviances from guidelines in the radiotherapy group (N=27) mainly concerned patient selecting this treatment due to expectations of preserving sexuality and/or fertility. CONCLUSIONS: In spite of acceptable overall compliance to guidelines for curative PCa treatment, the proportion of non-adherence should not been overseen, in particular when new treatment technologies are introduced. Guidelines for PCa need to be monitored regularly, and the compliance to guidelines has to be assessed on a regular basis. Guidelines should avoid too strict criteria, particularly in relation to age.

“Surgeon perception is not a good predictor of peri-operative outcomes in robot-assisted radical prostatectomy.”